A client was re-admitted to the hospital following a recent skull fracture. Which finding requires the nurse's immediate attention?
D) Hearing loss
Review Information: The correct answer is A: Lethargy
The level of consciousness or responsiveness is the most important measure of the client''s rising intracranial pressure. Look for lethargy, delay in response to verbal suggestions and slowing of speech. Assess for rising blood pressure or widening pulse pressure and for respiratory irregularities. There may be vomiting, usually projectile, without the presence of nausea.
A woman comes to the antepartum clinic for a routine prenatal examination. She is 12 weeks pregnant with her second child. Which of the following shows proper documentation of the client's obstetric history by the nurse?
A) Para 2, Gravida 1
B) Nulligravida 2, Para 1
C) Primigravida 1, Para 1
D) Gravida 2, Para 1
Review Information: The correct answer is D: Gravida 2, Para 1
Gravida describes a woman who is or has been pregnant, regardless of pregnancy outcome. Para describes the number of babies born past a point of viability. Therefore a woman pregnant with her second child would be described as Gravida 2, Para 1. Primipara refers to a woman who has completed one pregnancy to the period of viability. Multipara refers to a woman who has completed 2 or more pregnancies to the stage of viability.
The registered nurse (RN) is planning care at a team meeting for a 2 month-old child in bilateral leg casts for congenital clubfoot. Which of these outcomes suggested by the practical nurse (PN) should be considered the priority nursing goal following cast application?
A) The infant will experience minimal pain
B) Muscle spasms will be relieved
C) Mobility will be managed as tolerated
D) Tissue perfusion will be maintained
Review Information: The correct answer is D: Tissue perfusion will be maintained
Immediately following cast application, the chief goal is to maintain circulation and tissue perfusion around the cast. Permanent tissue damage can occur within a few hours if perfusion is not maintained.
A client is admitted with the diagnosis of myocardial infarction (MI). Which of the following lab values would be consistent with this diagnosis
A) Low serum albumin
B) High serum cholesterol
C) Abnormally low white blood cell count
D) Elevated creatinine phosphokinase (CPK)
Review Information: The correct answer is D: Elevated creatinine phosphokinase (CPK)
An elevated CPK is a common finding in the client with an MI. CPK levels begin to rise approximately 3 to 12 hours after an acute MI, peak in 24 hours, and return to normal within 2 to 3 days. Troponin levels rise as well.
The nurse is providing instructions for a client with asthma who is sensitive to house dust-mites. Which information about prevention of asthma episodes would be the most helpful to include during the teaching?
A) Change the pillow covers every month
B) Wash bed linens in warm water with a cold rinse
C) Wash and rinse the bed linens in hot water
D) Use air filters in the furnace system
Review Information: The correct answer is C: Wash and rinse the bed linens in hot water
For asthma clients who are sensitive to house dust-mites it is essential the mattresses and pillows are encased in allergen-impermeable covers. All bed linens such as pillow cases, sheets and blankets should be washed and rinsed weekly in hot water at temperatures above 130 degrees Fahrenheit, the temperature necessary to kill the dust-mites.
The nurse is teaching childbirth preparation classes. One woman asks about her rights to develop a birthing plan. Which response made by the nurse would be best?
A) "What is your reason for wanting such a plan?"
B) "Have you talked with your provider about this?"
C) "Let us discuss your rights as a couple"
D) "Write your ideal plan for the next class"
Review Information: The correct answer is C: "Let us discuss your rights as a couple"
Discussion of the provider''s role and the couple''s rights and limitations in selecting birth options must precede development of a plan.
A client is receiving oxygen therapy via a nasal cannula. When providing nursing care, which of the following interventions would be appropriate?
A) Determine that adequate mist is supplied
B) Inspect the nares and ears for skin breakdown
C) Lubricate the tips of the cannula before insertion
D) Maintain sterile technique when handling cannula
Review Information: The correct answer is B: Inspect the nares and ears for skin breakdown
Oxygen therapy can cause drying of the nasal mucosa. Pressure from the tubing can cause skin irritation. Nasal cannula administering oxygen should not be lubricated with petroleum jelly.
At a nursing staff meeting, there is discussion of perceived inequities in weekend staff assignments. As a follow-up, the nurse manager should initially
A) Allow the staff to change assignments
B) Clarify reasons for current assignments
C) Help staff see the complexity of issues
D) Facilitate creative thinking on staffing
Review Information: The correct answer is D: Facilitate creative thinking on staffing
The "moving phase" of change involves viewing the problem from a new perspective, and then incorporating new and different approaches to the problem. The manager, as a change agent, can facilitate staff''s solving the problem.
A 14 month-old had cleft palate surgical repair several days ago. The parents ask the nurse about feedings after discharge. Which lunch is the best example of an appropriate meal?
A) Hot dog, carrot sticks, gelatin, milk
B) Soup, blenderized soft foods, ice cream, milk
C) Peanut butter and jelly sandwich, chips, pudding, milk
D) Baked chicken, applesauce, cookie, milk
Review Information: The correct answer is B: Soup, blenderized soft foods, ice cream, milk
In a child with cleft palate repair, parents should prepare soft foods and avoid those foods with particles that might traumatize the surgical site.
A client tells the nurse he is fearful of planned surgery because of evil thoughts about a family member. What is the best initial response by the nurse?
A) Call a chaplain
B) Deny the feelings
C) Cite recovery statistics
D) Listen to the client
Review Information: The correct answer is D: Listen to the client
Therapeutic communications are based on attentive listening to expressed feelings. If the nurse is not familiar with the cultural beliefs of a client, acceptance of feelings is followed by questions about the beliefs.
A child with tetralogy of Fallot visits the clinic several weeks before planned surgery. The nurse should give priority attention to
A) assessment of oxygenation
B) observation for developmental delays
C) prevention of infection
D) maintenance of adequate nutrition
Review Information: The correct answer is A: assessment of oxygenation
All of the above would be important in a child diagnosed with tetralogy of Fallot. However, persistent hypoxemia causes acidosis which further decreases pulmonary blood flow. Additionally, low oxygenation leads to development of polycythemia and resultant neurologic complications.
In reviewing the assessment data of a client suspected of having diabetes insipidus, the nurse expects which of the following after a water deprivation test?
A) Increased edema and weight gain
B) Unchanged urine specific gravity
C) Rapid protein excretion
D) Decreased blood potassium
Review Information: The correct answer is B: Unchanged urine specific gravity
When fluids are restricted, the client continues to excrete large amounts of dilute urine. This finding supports the diagnosis. Normally, urine is more concentrated with reduced fluid intake.
The nurse is assessing a 12 year-old who has hemophilia A. Which finding would the nurse anticipate?
A) An excess of red blood cells
B) An excess of white blood cells
C) A deficiency of clotting factor VIII
D) A deficiency of clotting factors VIII and IX
Review Information: The correct answer is C: A deficiency of clotting factor VIII
Hemophilia A is characterized by an absence or deficiency of Factor VIII.
The nurse is assessing a client with a deep vein thrombosis. Which of the following signs and/or symptoms would the nurse anticipate finding?
A) Rapid respirations
C) Swelling of lower extremity
D) Positive Babinski's sign
Review Information: The correct answer is C: Swelling of lower extremity
The most common signs of deep vein thrombosis are pain in the region of the thrombus and unilateral swelling distal to the site.
When planning the care for a young adult client diagnosed with anorexia nervosa which of these concerns should the nurse determine to be the priority for long term mobility?
A) digestive problems
C) Electrolyte imbalance
D) blood disorders
Review Information: The correct answer is B: amenorrhea
Changes in reproductive hormones and in thyroid hormones can cause absence of menstruation, called amenorrhea, which contributes to osteoporosis and bone fractures.
The new graduate nurse interviews for a position in a nursing department of a large health care agency, described by the interviewer as having shared governance. Which of these statements best illustrates the shared governance model?
A) An appointed board oversees any administrative decisions
B) Nursing departments share responsibility for client outcomes
C) Staff groups are appointed to discuss nursing practice and client education issues
D) Non-nurse managers supervise nursing staff in groups of units
Review Information: The correct answer is B: Nursing departments share responsibility for client outcomes
Shared governance or self-governance is a method of organizational design that promotes empowerment of nurses to give them responsibility for client care issues.
The nurse is teaching a client about the healthy use of ego defense mechanisms. An appropriate goal for this client would be
A) Reduce fear and protect self-esteem
B) Minimize anxiety and delay apprehension
C) Avoid conflict and leave unpleasant situations
D) Increase independence and communicate more often
Review Information: The correct answer is A: Reduce fear and protect self-esteem
Ego defense mechanisms are unconscious proactive barriers that are used to manage instinct and affect in the presence of stressful situations. Healthy reactions are those in which the client admits that they are feeling various emotions.
The nurse is caring for a client with Parkinson's disease. The client spends over 1 hour to dress for scheduled therapies. What is the most appropriate action for the nurse to take in this situation?
A) Ask family members to dress the client
B) Encourage the client to dress more quickly
C) Allow the client the time needed to dress
D) Demonstrate methods on how to dress more quickly
Review Information: The correct answer is C: Allow the client the time needed to dress
Clients with Parkinson''s disease often wish to take care of themselves but become very upset when hurried and then are unable to manage at all. Any form of hurrying the client will result in a very upset and immobilized client.
The nurse would expect which eating disorder to cause the greatest fluctuations in potassium?
A) binge eating disorder
B) anorexia nervosa
D) purge syndrome
Review Information: The correct answer is C: bulimia
With bulimia the purging process tends to make the body dehydrated and to lower the level of potassium in the blood. Low potassium levels can cause weakness, abdominal cramping and irregular heart rhythms.
While performing an initial assessment on a newborn following a breech delivery, the nurse suspects hip dislocation. Which of the following is most suggestive of the abnormality?
A) Flexion of lower extremities
B) Negative Ortolani response
C) Lengthened leg of affected side
D) Irregular hip symmetry
Review Information: The correct answer is D: Irregular hip symmetry
Early assessment of irregular hip symmetry alerts the nurse and the provider to a correctable congenital hip dislocation.
The nurse is evaluating the growth and development of a toddler with AIDS. The nurse would anticipate finding that the child has
A) achieved developmental milestones at an erratic rate
B) delay in musculoskeletal development
C) displayed difficulty with speech development
D) delay in achievement of most developmental milestones
Review Information: The correct answer is D: delay in achievement of most developmental milestones
The majority of children with AIDS have neurological involvement. There is decreased brain growth as evidenced by microcephaly and abnormal neurologic findings. Developmental delays are common, and after achieving normal development, there may be loss of milestones. The other options are accurate but are too limited to be the best response.
When caring for a client with advanced cirrhosis of the liver, which nursing diagnosis should take priority?
A) risk for injury: hemorrhage
B) risk for injury related to peripheral neuropathy
C) altered nutrition: less than body requirements
D) fluid volume excess: ascites
Review Information: The correct answer is A: risk for injury: hemorrhage
Liver disease interferes with the production of prothrombin and other factors essential for blood clotting. Hemorrhage, especially from esophageal varices can be life threatening. This takes priority over the other nursing diagnosis.
When teaching new parents prevention of sudden infant death syndrome (SIDS) what is the most important practice the nurse should instruct them to do?
A) Place the infant in a supine or side lying position for sleep
B) Do not allow anyone to smoke in the home
C) Follow recommended immunization schedule
D) Be sure to check infant every one hour
Review Information: The correct answer is A: Place the infant in a supine or side lying position for sleep
Current thinking is that infants become hypoxic when they sleep because of positional narrowing of the airway and respiratory inflammation. The most compelling data comes from studies that link sleep habits with an increased risk of SIDS. Sleeping in the prone position may cause oropharyngeal obstruction or affect the thermal balance or arousal state. Sleep apnea is not the cause of SIDS. Because of research findings and the "Back to Sleep" campaign, the incidence of sleep apnea and the number of SIDS deaths have dropped dramatically.
In a long term rehabilitation care unit, a client with spinal cord injury complains of a pounding headache. The client is sitting in a wheelchair watching television. Further assessment by the nurse reveals excessive sweating, a splotchy rash, pilomotor erection, facial flushing, congested nasal passages and a heart rate of 50. The nurse should perform which action next?
A) Take the client's respirations, blood pressure (BP), temperature and then pupillary responses
B) Place the client into the bed and administer the ordered PRN analgesic
C) Check the client for bladder distention and the client's urinary catheter for kinks
D) Turn the television off and then assist client to use relaxation techniques
Review Information: The correct answer is C: Check the client for bladder distention and the client''s urinary catheter for kinks
These are findings of autonomic dysreflexia, also called hyperreflexia. This response occurs in clients with a spinal cord injury above the T-6 level. It is typically initiated by any noxious stimulus below the level of injury such as a full bladder, an enema or bowel movement, fecal impaction, uterine contractions, changing of the catheter, and vaginal or rectal examinations. The stimulus creates an exaggerated response of the sympathetic nervous system and can be a life-threatening event. The BP is typically extremely high. The priority action of the nurse is to identify and relieve the cause of the stimulus.
A 2 month-old infant has both a cleft lip and palate which will be repaired in stages. In the immediate postoperative period for a cleft lip repair, which nursing approach should be the priority?
A) Remove protective arm devices one at a time for short periods with supervision
B) Initiate by mouth feedings when alert, with the return of the gag reflex
C) Introduce to the parents how to cleanse the suture line with the prescribed protocol
D) Position the infant on the back after feedings throughout the day
Review Information: The correct answer is A: Remove protective arm devices one at a time for short periods with supervision
The major efforts in the postoperative period are directed toward protecting the operative site. Elbow restraints should be used and only 1 arm released at a time with close supervision by the nurse and/or parents.
In addition to disturbances in mental awareness and orientation, a client with cognitive impairment is also likely to show loss of ability in
A) Hearing, speech, and sight
B) Endurance, strength, and mobility
C) Learning, creativity, and judgment
D) Balance, flexibility, and coordination
Review Information: The correct answer is C: Learning, creativity, and judgment
Cognitive impairments are due to physiological processes that affect memory and other higher-level cognitive processes.
A client is admitted with a diagnosis of myocardial infarction (MI). The client is complaining of chest pain. The nurse knows that pain related to an MI is due to
A) insufficient oxygenation of the cardiac muscle
B) potential circulatory overload
C) left ventricular overload
D) electrolyte imbalance
Review Information: The correct answer is A: insufficient oxygenation of the cardiac muscle
Due to ischemia of the heart muscle, the client experiences pain. This happens because an MI can block or interfere with the normal cardiac circulation.
The nurse is caring for a client admitted to the hospital with right lower lobe (RLL) pneumonia. On assessment, the nurse notes crackles over the RLL. The client has significant pleuritic pain and is unable to take in a deep breath in order to cough effectively. Which nursing diagnosis would be most appropriate for this client based on this assessment data?
A) Impaired gas exchange related to acute infection and sputum production
B) Ineffective airway clearance related to sputum production and ineffective cough
C) Ineffective breathing pattern related to acute infection
D) Anxiety related to hospitalization and role conflict
Review Information: The correct answer is B: Ineffective airway clearance related to sputum production and ineffective cough
Ineffective airway clearance is defined as the inability to cough effectively. While the other diagnoses may be appropriate for this client, this is the only one supported directly by the assessment data given.
On initial examination of a 15 month-old child with suspected otitis media, which group of findings would the registered nurse (RN) anticipate?
A) Periorbital edema, absent light reflex and translucent tympanic membrane
B) Irritability, rhinorrhea, and bulging tympanic membrane
C) Diarrhea, retracted tympanic membrane and enlarged parotid gland
D) Vomiting, pulling at ears and pearly white tympanic membrane
Review Information: The correct answer is B: Irritability, rhinorrhea, and bulging tympanic membrane
Clinical manifestations of otitis media include irritability, rhinorrhea, bulging tympanic membrane, and pulling at ears.
A Hispanic client refuses emergency room treatment until a curandero is called. The nurse understands that this person brings what to situations of illness?
A) Holistic healing
B) Spiritual advising
C) Herbal preparations
D) Witchcraft potions
Review Information: The correct answer is A: Holistic healing
This traditional folk practitioner uses holistic methods for illnesses not related to witchcraft. Many times, the curandero works with traditional health care providers to restore health.
The nurse is caring for a client with left ventricular heart failure. Which one of the following assessments is an early indication of inadequate oxygen transport?
A) crackles in the lungs
B) confusion and restlessness
C) distended neck veins
D) use of accessory muscles
Review Information: The correct answer is B: confusion and restlessness
Neurological changes, including impaired mental status, are early signs of inadequate oxygenation.
Postoperative orders for a client undergoing a mitral valve replacement include monitoring pulmonary artery pressure together with pulmonary capillary wedge pressure with a pulmonary artery catheter. The purpose of these actions by the nurse is to assess
A) right ventricular pressure
B) left ventricular end-diastolic pressure
C) acid-base balance
D) coronary artery stability
Review Information: The correct answer is B: left ventricular end-diastolic pressure
The pulmonary capillary wedge pressure is reflective of left ventricular end-diastolic pressure. Pulmonary artery pressures are an assessment tool used to determine the ability of the heart to receive and pump blood effectively.
A 6 year-old female is diagnosed with recurrent urinary tract infections (UTIs). Which one of the following instructions would be best for the nurse to tell the caregiver?
A) Increase bladder tone by delaying voiding
B) When laundering clothing, rinse several times
C) Use plain water for the bath, shampooing hair last
D) Have the child use antibacterial soaps while bathing
Review Information: The correct answer is C: Use plain water for the bath, shampooing hair last
Hair should be shampooed last with a rinsing of plain water over the genital area. The oils in soaps and bubble bath can cause irritation, which may lead to UTI''s in young girls.
The nurse is performing a physical assessment on a client with insulin dependent diabetes mellitus. Which client finding calls for immediate nursing action?
A) Diaphoresis and shakiness
B) Reduced lower leg sensation
C) Intense thirst and hunger
D) Painful hematoma on thigh
Review Information: The correct answer is A: Diaphoresis and shakiness
Diaphoresis is a sign of hypoglycemia which warrants immediate attention.
A client is admitted with a distended bladder due to the inability to void. The nurse obtains an order to catheterize the client, and is aware that gradual emptying is preferred over complete emptying because it reduces the
A) potential for renal collapse
B) potential for shock
C) intensity of bladder spasms
D) chance of bladder atrophy
Review Information: The correct answer is B: potential for shock
Complete, rapid emptying can cause shock and hypotension due to sudden changes in the abdominal cavity.
A client was admitted with a diagnosis of pneumonia. When auscultating the client's breath sounds, the nurse hears inspiratory crackles in the right base. Temperature is 102.3 degrees Fahrenheit orally. What other finding would the nurse expect?
A) Flushed skin
C) Mental confusion
Review Information: The correct answer is C: Mental confusion
Crackles suggest pneumonia, which is likely to be accompanied by mental confusion related to hypoxia.
The nurse is assessing a newborn infant and observes low set ears, short palpebral fissures, flat nasal bridge and indistinct philtrum. A priority maternal assessment by the nurse should be to ask about
A) alcohol use during pregnancy
B) usual nutritional intake
C) family genetic disorders
D) maternal and paternal ages
Review Information: The correct answer is A: alcohol use during pregnancy
This cluster of facial characteristics is often linked to fetal alcohol syndrome (FAS). Lifelong developmental delays of varying severity can result.
The nurse is planning care for a client with increased intracranial pressure. The best position for this client is
D) Side-lying with head flat
Review Information: The correct answer is C: Semi-Fowlers
Maintaining the head of the bed at 15-30 degrees reduces cerebral venous congestion.
You are teaching a client about the patient controlled analgesia (PCA) planned for post-operative care. Which statement indicates further teaching may be needed by the client?
A) "I will be receiving continuous doses of medication."
B) "I should call the nurse before I take additional doses."
C) "I will call for assistance if my pain is not relieved."
D) "The machine will prevent an overdose."
Review Information: The correct answer is B: "I should call the nurse before I take additional doses."
Patient controlled analgesia offers the client more control. The client should be instructed to initiate additional doses as needed without asking for assistance unless there is insufficient control of the pain.
A young child is admitted for treatment of lead poisoning. The nurse recognizes that the most serious effect of chronic lead poisoning is
A) central nervous system damage
B) moderate anemia
C) renal tubule damage
D) growth impairment
Review Information: The correct answer is A: central nervous system damage
The most serious consequences of chronic lead poisoning occur in the central nervous system. Neural cells are destroyed by the toxic effects of the lead, resulting in many problems with the intellect ranging from mild deficits to mental retardation and even death.